21 Things You Should Know About Japanese Food | Ever In Transit

Food is very serious business in Japan.

Though I spend a lot of time thinking about the things I eat, I was still blown away by how much thought goes into the preparation, consumption, and appreciation of Japanese food. There is a level of obsession with food in Japan that I’ve never seen anywhere else.

If you love to eat and enjoy exploring food, culture, and culinary traditions, Japan should be at the top of your world travel bucket list.

Here are some things you should know about Japanese food:

1. Japanese cuisine is one of only three national food traditions recognized by the UN for its cultural significance

Last December, UNESCO, the United Nation’s cultural organization, added traditional Japanese cuisine, or washoku, into its Intangible Cultural Heritage list meaning that the preservation of this way of eating is vital to the survival of the traditional culture. It was only the second national traditional cuisine honored as such, after French food. (Mexican cuisine has recently joined the list.)


2. Japanese food is prepared carefully using seasonal ingredients and flavors

Japanese food is as much about the preparation and presentation as it is the food itself. A great deal of thought goes into every item served. While we think of only four annual seasons, Japanese chefs consider dozens of seasons and carefully select ingredients that are in their prime with flavors that represent that specific period. Because we visited in the very early spring (beginning of March) every meal that we tried included bitter components which is a typical flavor for this season. Tasting these flavors, connects Japanese eaters with years past.

Once finished, the food is carefully plated and the finished dish often looks like a work of art.


3. Simplicity is key

Courses include a few small items, often fresh and with simple flavors. Japanese chefs work with top quality ingredients and do as little to the food as possible to bring out the color and flavor.


4. Infrequent use of garlic, chile peppers, and oil

Many foods are seared, boiled or eaten raw and minimally seasoned. Umami (a rich flavor profile characteristic of Japanese food) is enhanced by using just a few ingredients including miso, soy sauce, mushrooms, seaweed, bonito flakes, and bonito broth. When foods are fried (like tempura) the batter is thin and absorbs very little oil.


5. Condiments add diversity

To add contrast to the food, simple condiments are often added to enhance the flavors. Light dipping sauces, citrus, miso, wasabi, pickles, and soy sauce may be included with the course.


6. It doesn’t look like a lot of food but it is!

Though the individual servings are small, traditional Japanese meals (called kaiseki) include several courses which add up to a lot of food. You will fill up.


7. The choice of dishes is important

While Western cultures tend to appreciate matching dishware, Japanese cooks tend to use dishes with a variety of colorful patterns, shapes and colors. The specific choice of dishes is important and seasonal. Fine restaurants will often use antique ceramics and lacquerware. When your server brings you a course, after asking what the food is, it is expected that you will also ask them to tell you about the dishes. The hand-painted bowl below (from a restaurant in Kyoto) was over 200 years old! It was selected because the leafy pattern represents the early spring season during which we visited, and it also provides a contrast between the old and the new green shoots of spring.


8. Tokyo has some of the best restaurants in the world

With 14 Michelin three-star restaurants, Tokyo has more top-rated restaurants than any other city, surpassing even Paris.


9. Traditional restaurants don’t have low-wage ‘wait staff’

Apprentice chefs sometimes work in restaurants for ten years before they are allowed to handle the fish or meat. During that time they bus tables, serve meals, and do manual tasks like making rice. Still, these apprentices earn decent wages and it is considered an insult to tip them.

Hamming it up with the chef at Kyoto’s Kiyojirou restaurant.

10. The seafood industry is HUGE!

As seafood is a major part of the Japanese diet, the seafood fishing and import industry in Japan is staggering. Tsukiji Market in Tokyo is the world’s largest wholesale markets for fresh, frozen, and processed seafood and sells over 700,000 tons of seafood each year. In this photo below, this massive market complex takes up all of the low-rise buildings in the foreground (lower 2/3 of the photo). And this is just one of 12 wholesale fish markets in Tokyo alone!


11. Japanese meals include a lot of vegetables but finding completely vegetarian food is hard

Japanese cuisine has a much higher ratio of plant-based foods than is typical in the U.S., but it is still hard to eat completely vegetarian. This is because many traditional dishes are cooked in fish broth or are sprinkled with bonito flakes. I’m vegetarian, and though we did our best to find plant-based alternatives within the traditional menus, there were a few times when I ate things that were not strictly vegetarian because they were cooked in fish broth, or which I had to scrape off the bonito flakes. That was fine with me, I was willing to do that in order to experience traditional food culture. Travelers that avoid seafood for religious reasons or because of allergies will find it a bit harder to stick to their diet. For more tips, check out this post: A Guide To Vegetarian Food In Japan


12. Japanese people love beautifully crafted and gift-wrapped sweets

Every region of Japan has different styles of typical traditional sweets, known as wagashi. These delicate creations are often sold in beautifully wrapped boxes, in convenience stores and in train stations because they are customarily given as gifts to friends and family. One of my favorite sweets was Kyoto’s yatsuhashi (shown below), thin, triangle-shaped sweet rice wrappers filled with red bean paste.

Just whatever you do, don’t eat the sweets on the sidewalk or while standing or walking anywhere in public. Eating anything, anywhere outside of restaurants and food-serving establishments is considered rude! And that brings me to…


13. Japan’s many food rules and food etiquette

There are lots of rules for proper etiquette that apply to every aspect of life in Japan, including food. Some of these I had heard before we arrived, like it is polite to make a slurping sound when eating noodle soups, though, you should not slurp if you are eating soup made with rice. Sticking your chopsticks straight up in a bowl of rice is very rude, as is (to a lesser extent) laying your chopsticks across the bowl you are eating from. Always use the chopstick stand (if provided), and if not, fold the paper chopstick wrapper into a tent shape and rest the tips of the chopsticks on that. More rules on Japanese etiquette will be covered in a future post.


14. It’s rude to leave a messy plate

Another etiquette rule that surprised me is that you’re not supposed to leave your plates covered with a pile of crumpled up napkins and garbage. Our guide told us that shows a lack of respect for the restaurant staff and the meal they served. She suggested we fold (or even tie a bow!) in our used napkins.


15. An interesting way to pour sake

Restaurants will often pour sake until it spills over into a saucer, as a token of appreciation for your visit. The overflowing glass signifies abundance and gratitude. Don’t be surprised when they do this:


16. Tea as art

The traditional tea practice ( chado) is considered one of the Japan’s highest forms of art, alongside calligraphy, music, and theater. Aspiring practitioners study for years to earn the honor of serving a traditional tea. It’s expected that corporate CEOs (as leaders in their community) study and learn traditional forms of Japanese art, including the way of tea.


17. Different regions feature locally grown ingredients in their confectons

In Northern Japan’s Miyagi Prefecture (a region known for soybean production) edemame is used in all the local wagashi sweets, like Northern Japan’s zundamochi (shown below) and edemame ice cream. Corporate copycat, Nestlé, even sells edemame flavored Kit Kat bars!


18. Luxury fruit and high-end food imports from around the world

Japan’s specialty farmers grow high-quality fruit especially melons and strawberries. There are certain prized varieties of cantaloupe, grown under carefully controlled conditions that sell for $200 each! (Believe me: I saw one in a department store!) And if there is anything else from around the world that you enjoy eating, you can probably find it in Tokyo. For example, Pierre Herme, my favorite Parisian macaron maker maker has, not one, but ELEVEN patisseries in Tokyo (number in the U.S. – zero).


19. Dining on a Budget

Dining out in Japan is expensive (especially in Tokyo) but there are delicious and hearty options for travelers on a budget. For example, you can almost always find a hearty bowl of ramen at local ramen shops for under $10. Because tiny restaurants like this specialize on a single dish, the quality is excellent and they can sell it to you for cheap.


20. Picky eaters beware!

Some Japanese food experiences (including visits to seafood markets) are NOT for the faint of heart! Local food markets feature all manner of slimy and wiggly sea creatures (some sold and even eaten alive!), giant tuna eyeballs (that we found at the Shiogama Fish Market), and have floors puddled with blood. The local tradition is to eat every part of the sea creature and the daily catch, so remind yourself how sustainable that is if you find yourself getting grossed out.


21. Japan has impeccable food safety and cleanliness standards so it is safe to buy food anywhere

Get the urge to buy sushi from a 7-11 convenience store or from a magazine vendor in the subway station? Do it. You won’t get sick.

Interested in learning more about Japanese food culture? Please check out this new book, ‘ Rice, Noodle, Fish: Deep Travels Through Japan’s Food Culture.’ It was written by the editor of Roads and Kingdoms (travel, food, and culture website) with the support of Anthony Bourdain. It’s a great read.

Want to save this post? Click below to pin it on Pinterest: This trip to Japan was supported by the Japanese Ministry of Foreign Affairs. All thoughts and opinions are my own.

Bucket List Heros Launches Global Travel Business Platform

Atlanta, GA — September 12, 2016 — Navigator International, Inc. has announced the launch of a proprietary marketing system aimed at opening the $8+ trillion worldwide travel industry to home-based business owners like never before. The Bucket List Tools system offers entrepreneurs powerful proven technologies that help facilitate massive duplication and results for people who have no experience, leveling the playing field for the masses to achieve success.

Company president Camaron Corr commented, “The landscape of the direct sales industry has changed over the course of the last decade. Customers and regulators are focused on product value, and entrepreneurs have increased their expectations about the tools needed to be successful. The Bucket List Tools system raises the bar for the entire industry. There has simply never been anything like this!”

Having previously built one of the largest travel businesses in the history of the industry with more than 230,000 distributors, Corr continued, “I know what it takes to help a team of ‘Average Joes’ break out and truly be successful, but with all that success we never had anything close to the power and simplicity of this system. People can literally change their lives by plugging into this technology. It’s an absolute game changer.”

Bucket List Tools was developed by the “WWW Guy”, industry marketing veteran, Mike Darling. The platform (available at includes a full portfolio of professional websites, sales funnels, and powerful marketing tools designed to empower the novice entrepreneur to achieve success like never before. Built for the exclusive use of the Bucket List Heros team, the system was custom designed based on 20+ years of proven technology and experience.

“After decades developing marketing systems for companies,” remarked Darling, “I made the decision to leave the vendor space behind in order to engage directly with the field, and develop the most powerful system yet! Creating a fully integrated system where literally every line of code is truly custom designed for this specific business building process, we’ve been able to take the technology to the next level in ways no company or software vendor could ever justify doing. The era of the unsolicited outbound sales pitch is over. ‘Pull’ has replaced ‘push’ and inbound marketing is king. Trust is built with customers by providing true value up front, and at no cost. Product information is shared, not sold. This is exactly what the Bucket List Tools system is all about. Historically we charged $100’s per month for a fraction of this technology, yet it’s made available here for free!”

Corr added, “People are having a blast while earning an income! And the lifestyle change can be profound as they travel to the exotic locations they’ve always dreamed about. Travel Opportunity is a product that sells itself. After all, who wouldn’t like to get a 5-star vacation experience at a 1-star price? We have a product that everybody wants! And now people can literally ‘eat’ their way on to a vacation as well by earning travel credits at restaurants they’re already dining at!”

About Navigator International, Inc:

Camaron Corr is recognized as one of the top Network Marketing Professionals in the world. He is a sought-after trainer, coach, mentor and speaker that has been featured in Success Magazine and many other industry publications. His success in the travel arena is well documented, having built a business with his team to over 4.5 million customers. He has earned millions of dollars in commissions himself, but his true passion is helping others, including many that have become millionaires as well.

About The WWW Guy:

Since 1996, Mike Darling’s systems and consulting services have been utilized by more than 70 direct sales companies to empower their distributors. Specializing in automated online marketing systems, lead generation, and search engine optimization (SEO), the technology is widely acknowledged as having pioneered many of the services considered internet marketing standards today and have been utilized by over 20 million system users in 163 countries.

Source: http://markets.securitiesindustry.com/sourcemedia.securitiesindustry/news/read/32823210/Bucket_List_Heros_Launches_Global_Travel_Business_Platform

What Research About Jobs Can Teach You

Getting a Private Pilot Certificate

People sometimes dream of flying the skies in their very own airplane and hence become a private pilot; if this is your dream as well then make sure you read this article. People are rarely happy with their career choice but this one will truly bring out the joy in them. There are various factors to keep in mind when engaging in this professional venture.

Weather conditions are things you have to know about on a regular basis if you dream of flying high. When you go up there, you have to keep in mind that everything has to be within your favor and that you and your passengers would be safe at all times. These are among the many considerations people have to be aware of when pursuing this kind of dream. When you fly a plane, there has to be no doubt that you’re an expert because that would surely help you in more ways than one.

There are various things you need to learn about including everything that happens in the air. Knowing where you are located would be the key to safe travels in so many ways. Do your research concerning these matters because it would not be enough to just go to pilot school. One has to be aware of the details of the continent and ocean masses he is traveling in. There are certain categories which have to be considered when it comes to these things. One can become a really good private pilot with the help of these tips and guidelines. Water activity is essential to know about when traveling over it. This would be a journey that would get you safely to a particular destination. One would definitely know the best way to fly when fully aware of the different variations. Both pilot and passenger should be aware of the basics of traveling on air. Professionals fly in various ways and there are certain things that would influence the way they go about the entire process. Flying would come much easier when the air is clear. If the weather is clear then you shouldn’t have to bother yourself about thunderstorms.

It’s so much more ideal when you’re able to travel smoothly in warm weather; this the dream of every private pilot out there. If this is kind the of weather you are facing then travel difficulties won’t have to bother you at all. Your plane would be steady and you’d be flying like a professional all year round because of the skills you learned in pilot school.

Source: Jeff Phoenix Coursey

Cultural Competence for Clinicians

Enhancing Your Cultural Communication Skills

There are several ways in which clinicians working with multicultural patients & families can contribute to our customers’ positive experience at UMHS. An important first step is to be sensitive to patients’ cultural beliefs and practices and to convey our respect for their cultural values through the manner in which we communicate with them and deliver their healthcare. This may require calling for help in interpreting behavior, either from a provider who is from the same ethnic group as the patient or from an expert familiar with the group’s language, life-style, and value preferences.

It is critical that health care providers recognize individual differences and do not participate in ‘cultural stereotyping’. Because persons of the same ethnicity can have very different beliefs and practices, it is important to understand the particular circumstances of the patient or family by obtaining information on: place of origin; social and economic background; degree of acculturation; and personal expectations concerning health and medical care.

The following questions may be useful in assessing culturally diverse patients and families:

  1. So that I might be aware of and respect your cultural beliefs,
  2. Can you tell me what languages are spoken in your home and the languages that you understand and speak?
  3. Please describe your usual diet. Also, are there times during the year when you change your diet in celebration of religious and other ethnic holidays?
  4. Can you tell me about beliefs and practices including special events such as birth, marriage and death that you feel I should know?
  5. Can you tell me about your experiences with health care providers in your native country? How often each year did you see a health care provider before you arrived in the U.S.? Have you noticed any differences between the type of care you received in your native country and the type you receive here? If yes, could you tell me about those differences?
  6. Is there anything else you would like to know? Do you have any questions for me? (Encourage two-way communication)
  7. Do you use any traditional health remedies to improve your health?
  8. Is there someone, in addition to yourself, with whom you want us to discuss your medical condition?
  9. Are there certain health care procedures and tests which your culture prohibits?
  10. Are there any other cultural considerations I should know about to serve your health needs?

Attitudes of the Culturally Competent Clinician

Understanding: Acknowledging that there can be differences between our Western and other cultures’ healthcare values and practices.

Empathy: Being sensitive to the feeling of being different.

Patience: Understanding the potential differences between our Western and other cultures’ concept of time and immediacy.

Respect:

  • The importance of culture as a determinant of health;
  • The existence of other world views regarding health/illness;
  • The adaptability and survival skills of our patients;
  • The influence of religious beliefs on health; and
  • The role of bilingual/bicultural staff.

Ability: To laugh with oneself and others.

Trust: Investment in building a relationship with patients which conveys a commitment to safeguard their well-being.

For more assistance or information, call The Program for Multicultural Health at (734) 998-9800, or the UMHS Interpreter Services at (734) 936-7021.

How to Work with a Foreign Language Interpreter

Speak in short units of speech – not long involved sentences or paragraphs. The UMHS interpreters use the Consecutive Interpreting format. This is where the providers and clients take turns speaking and the interpreter interprets at the end of each turn. The longer either party talks, the greater the margin of error.

Be patient. An interpreted interview takes longer. Careful interpretation often requires that the interpreter use long explanatory phrases. Not all words and thought exist in other languages; therefore, interpreting in another language may require more words to express the same meaning.

Expect that the interpreter may occasionally pause to ask you for an explanation or clarification of terms in order to provide an accurate interpretation.

Avoid colloquialism, abstractions, idiomatic expression, slang, similes, and metaphors.

During the interaction, look at and speak directly to the client, not to the interpreter. The interpreter will stand behind and a little to the side of the patient to assist in this interaction.

Avoid saying to the interpreter, ‘Ask him . . .’ or ‘Tell her . . .’. Speak in first person, as will the interpreter.

The interpreter will relay all that is said in the presence of the client and will not omit anything spoken on the side or anything that is said to others in the room.

Listen to the client and watch their nonverbal communication. Often you can learn a lot regarding the affective aspects of the client’s response by observing facial expressions, voice intonations, and body movements.

Repeat important information more than once. Always give the reason or purpose for a treatment or prescription.

Check the client’s understanding and accuracy of the interpretation by asking the client to repeat instructions or whatever has been communicated in his or her own words, with the interpreter facilitating.

When possible, reinforce verbal interaction with materials written in the client’s language and/or with visual aids. Do not use computer software to translate any written information. The translations are not accurate.

Realize that the interpreter can not reveal any information or opinions about the patients. Do ask the interpreter to clarify any cultural norms.

A videotape is available for loan from UMHS Interpreter Services entitled ‘Communicating Effectively Through an Interpreter’. Call (734) 936-7021.

Suggested Content for Enhancing Cultural Competency

Among Health Care Providers

Etiquette and Communication

  1. Interview and assess patients in the target language or via appropriate use of bilingual/bicultural interpreter.
  2. Ask questions to increase your understanding of the patient’s culture as it relates to health care practices.
  3. Where appropriate, formulate treatment plans which take into account cultural beliefs and practices.
  4. Write instructions or use handouts if available.
  5. Effectively utilize community resources.
  6. Request the patient to repeat information provided by healthcare professionals to ascertain understanding of message – educational and language barriers.
  7. Clearly communicate expectations (speak slower, not louder). Use drawings and gestures to aid communication.
  8. Make no assumptions about education level or professionalism.
  9. Avoid using phrases such as culturally insensitive terms, i.e., ‘You People’ and ‘Culturally Deprived’ which may be considered culturally insensitive.
  10. A reflective approach is useful. Health care providers should examine their own biases and expectations to understand how these influence their interactions and decision making.
  11. Listen carefully.

The following ‘cultural highlights’ although not all-inclusive may assist clinicians in interacting with patients from these cultures. Again, ‘cultural stereotyping’ should be avoided.

African American Patients

  • Address patients by their formal name, not by their first name, especially for elderly patients.
  • Make direct eye contact.
  • Explain reason for obtaining information since there may be reluctance to engage in personal disclosure.
  • Be cognizant of basic distrust of health professionals by many African Americans.
  • Chinese Patients

  • Ask about his/her last name and how to address him/her (husband and wife don’t necessarily have the same last name). People from China tend to be more formal than Americans.
  • Assertive and individualistic personalities may be considered crude and poorly socialized. This may mean that patients will not speak up in their own behalf.
  • Treatment decisions are often made by the family, rather than by the individual patient. The patient may want conversations about treatment to take place when the family is present. Ask the patient if this is his/her preference.
  • Patients may believe symptom relief should happen quickly, but they may also think the illness is cured when the symptoms go away. Pointing out progress or improvement may make results more obvious and act as an incentive for the patient to continue treatment.
  • Be aware of the importance of the Chinese patient in ‘saving face’. A response to yes/no questions is likely to be ‘yes,’ a nod, or ‘I know.’ These responses may not indicate understanding; they may simply mean that the patient has heard you. Ask the patient or family to repeat the information.
  • Explain why blood drawing for tests is important. Chinese patients believe that blood is the source of life for the entire body and it is not regenerated.
    • Be aware that Islamic patients tend to demonstrate passivity in the presence of an authority figure.
    • Explain the need for requesting patients to disclose personal information. Islamic patients may be reluctant to share such content with others.
    • Consider sharing some bit of personal information to gain the patient’s trust.
    • Ask about including a family spokesperson rather than only communicating with the patient.
    • Control the tendency to be ‘frank’ when communicating a grave diagnosis or a poor prognosis.
    • Japanese Patients

      • Doctors are seen as authority figures and patients and their families may hesitate to ask questions. Ask the patient or family members if they have questions more than once.
      • Treatment decisions are often made by the family, rather than by the individual patient. The patient may want conversations about treatment to take place when the family is present. Ask the patient if this is his/her preference.
      • Patients, particularly the elderly, are not accustomed to verbalizing their emotions. However, they appreciate empathy, sympathy, respect, and kindness. Nonverbal communication is important.

      Latino Patients

    • Involve the entire family in order to improve patient compliance. With a child’s treatment, it is imperative to involve both parents.
    • Inquire about what personal health treatments they may use (folk medicine).
    • Inquire about food choices. Latino patients believe in hot and cold food items to treat disease.

    Russian Patients

  • In Russia, bad news is not given to patients. Patients may demand to hear the truth but they do not want to hear the bad news. Talk to their relatives first.
  • Be aware that Russian patients and families may ask for new treatments or procedures. Patients expect doctors to explain, in detail, new tests or new medicines.
  • When explaining possible risks, complications and side effects of different procedures, be cautious and optimistic; Russian patients may overreact.
  • Russian patients are distrustful of doctors. They tend to disobey doctor’s orders such as not taking medications as prescribed or combining them with Russian treatments.
  • Russian patients prefer alternative methods or treatment such as massage or mud-therapy, a popular treatment in Russia. Russian patients are more likely to follow through with a homeopathic remedy versus traditional Western medicine.
  • Psychiatric disease is disgraceful in Russia. Russian patients often do not provide answers regarding any family history of psychiatric illness or past psychiatric treatments. The same holds true for sexual history.
  • Health and health care of Japanese American

    HEALTH AND HEALTH CARE OF
    JAPANESE-AMERICAN ELDERS
    Marianne K.G. Tanabe, M.D.

    Department of Geriatric Medicine, John A. Burns School of Medicine
    University of Hawaii

    DESCRIPTION

    This module reviews the demographics, history, health risks, and traditional health views of Japanese American elders. Suggestions for issues to consider in assessment and treatment are also included. The module is designed to use in conjunction with the Core Curriculum in Ethnogeriatrics.

    LEARNING OBJECTIVES

    After completing the module, learners should be able to:

    1. Describe briefly the history of Japanese immigration to the U.S.
    2. Identify and explain three areas of health care assessment and treatment that may be affected by the level of acculturation of the older Japanese American patient.
    3. Discuss the impact of Shintoism and Buddhism on end of life care.
    4. List three health risks that have changed over time in the U.S. for the Japanese American population.

    CONTENT

    I. Introduction and Overview

    A. Demographics*

    In the 2000 census, 796,700 residents of the U.S. identified their ‘race’ as Japanese, although there are likely to be many more of Japanese ancestry among the 1.6 million Asians who indicated their background included two or more ‘races’. In the 1990 census, 847,562 residents of the U.S. identified themselves as Japanese Americans, with about 52% living in California and 41% in Hawaii. Of these, 104, 932 were 65 years or older, 17.2% of whom were not born in the United States. For other characteristics of Japanese American elders from the 1990 census, see the chart in the Introduction section of the Asian/Pacific Islander modules.

    For further information, see the census web site www.census.gov.

    Most immigration to the United States from Japan occurred in the late 1800s to early 1900s. The generations in the U.S. are often referred by numbering the generations, i.e. first, second, third. The terms are in fairly common usage and include: 1) issei, the generation born in Japan who came to the U.S.; 2) nisei, the first generation born in the U.S., 3) sansei, the next generation; 4) yonsei, children of the sansei. Kibbei is the term used to describe Japanese Americans who were born in the U.S., sent abroad to Japan to be educated and who then returned to the U.S. It should be recognized that for any given individual, the generational terms are not related to age. An elder could be of any generation, and currently most are nisei and sansei.

    B. Language

    Compared to other American elders of Asian background, a much higher percentage of Japanese elders speak English. In 1990, only 36% said they did not speak English very well. Although the spoken Japanese language is different from the Chinese language, between the fourth and fifth century, the Japanese borrowed written Chinese characters and further adapted them for their use. The Japanese language is one of syllables. Inherent in the spoken language is the degree of politeness used to address others of different social status. Just as in the United States, regional accents exist as well as some dialects. The Okinawan native dialect, for example, is incomprehensible to mainstream Japanese, and immigrants from Okinawa often faced discrimination from immigrants from Japan within the Japanese community. This discrimination was probably rooted in a very interesting history of Okinawa, at one time an independent kingdom with close ties to China.

    *With a few exceptions, there are no references cited in the text. Information is taken from the sources listed in the Reference List in the last section of the module.

    C. Religion

    In Japan, generally speaking, two religions – Shintoism and Buddhism, and one code of ethics – Confucianism, have influenced the Japanese way of life and view of the world. Shintoism is the indigenous religion of Japan with origins in prehistoric Japan. It is based on the appreciation of nature and the belief in ‘kami’ or spirit gods existing in nature- mountains, trees, rocks, etc. It emphasizes cleanliness and purity. Being unclean and impure is considered disrespectful to the spirit gods. Therefore, before entering a Shinto shrine one must wash his hands in the designated wash area. Torii gates, usually three consecutive torii gates, leading to the shrine are symbolic for purifying the heart and mind before entering the shrine.

    Buddhism was introduced to Japan by way of Korea in 500 to 600 AD. Prince Shotoku of Japan converted to Buddhism in the 7th century and Buddhism subsequently flourished. Conflicts between Buddhism and Shintoism arose and were resolved by two Buddhist saints in the 8th century by devising a doctrine basically stating that no conflict exists between the two religions and that Buddha was a form of the old Shinto gods. During the time of Japanese immigration abroad, the majority of Japanese accepted both religions. Thus birth and marriage rites were Shinto rituals and end of life beliefs and funerals were often Buddhist. Confucianism was also important in influencing the Japanese culture and way of life. Confucianism is really a code of ethics with origins in China placing importance on family and social order. Thus inherent in the importance of family becomes the importance of taking care of one’s parents, or filial piety.

    II. Patterns of Health Risk

    The Honolulu Heart Program studies began in 1965 with a cohort of 8006 Japanese American men and is still continuing. Much of what we know about the health and aging of Japanese Americans is based on the several hundred publications that have come out of the studies of these men, and now some women, as they age.

    The cohort of Japanese men in the Honolulu Heart Program studies has a life expectancy that is longer than their counterparts in Japan, and Japan has the longest life expectancy of any country in the world. With a few exceptions noted below, the risk of most diseases that have been studied is lower among Japanese American elders than among other older Americans.

    A. Heart, Cardiovascular Disease, and Stroke

    Japanese Americans have been found to have much lower risks of heart and cardiovascular diseases than their white American counterparts. With increasing adaptation to the western diet (high meat, less roughage), however, there appears to be an increase in coronary artery disease.

    The Honolulu Heart Study cohort was found to have a lower risk for strokes than men in Japan. The incidence of strokes also declined during the first two decades since the inception of the studies. This decline was felt to be possibly related to a decline in blood pressure and smoking. However, there is a higher risk of hemorrhagic stroke among Japanese American men compared to Caucasian men. One theory is that this may be related to the lower fibrinogen levels found in a study by Iso et al. (1989).

    B. Cancer

    Breast cancer in older Japanese American women is lower than in most other U.S. populations. Ovarian and prostate cancer is also low, although longer residence in North America has been correlated with an increase in risk for prostate cancer, which in turn has been noted to be associated with increased saturated fat intake. Likewise colon cancer seems to be increasing with the adaptation to Western diets. Japanese Americans have a rate of stomach cancer that is twice as high as most other populations in the U.S., which is thought to be related to eating nitrite-rich salty foods (e.g. cured meats).

    C. Diabetes

    One disease that has a higher prevalence among Japanese Americans than their counterparts in either Japan or Caucasians in the U.S. is Type II Diabetes. In Seattle studies, 20% of Nisei men between 45 and 74 were found to have diabetes, half of which was not diagnosed, and 56% had abnormal glucose tolerance. Those rates are over twice as high as comparable samples of men in the U.S. population in general (Fujimoto et al., 1987). Those with diabetes were found to consume more fat and animal protein than their non-diabetic Nisei counterparts, although both groups consumed the same amount of calories.

    D. Dementia

    With the general longevity among the Japanese and the reluctance to report alterations in mental status, the frequency of undiagnosed dementia may be common. In the Honolulu-Asia Aging Study, the prevalence of vascular dementia among Japanese-American men appears to be higher than Caucasian men. The prevalence of Alzheimer disease appears to be similar to Caucasian men but higher than in Japan.

    III. Culturally Appropriate Geriatric Care: Fund of Knowledge

    To care for Japanese American elders effectively, it is important for providers to have background knowledge concerning: 1) the historical experiences of the cohort of elders and 2) traditional Japanese health beliefs and practices.

    A. Historical Experiences of the Cohort

    The reasons for immigration to the United States from Japan in the late 1800s and early 1900s were varied but occurred during Japan’s transition to a modern economy with its accompanying upheaval. Most of the Japanese immigrated for work and economic opportunity. The Hawaiian sugar industry boom brought many Japanese to Hawaii so that in 1910, Hawaii had four times as many Japanese as the U.S. mainland. It is said that between 1882 and 1908, 150,000 Japanese moved to Hawaii and about 30,000 to California. On the mainland, economic opportunity initially came primarily in the form of domestic and unskilled labor, for example work in logging or building railroads. During this time, the native born Japanese group was growing, and by 1930, native-born Japanese Americans were said to exceed those born in Japan by eighty percent. Many initially worked as contract laborers and subsequently when the opportunity arose, they acquired land or built businesses.

    The widespread internment of all Japanese Americans on the West Coast during World War II had a devastating effect, especially economically. Businesses built up over a lifetime had to be sold or liquidated quickly, with great losses. Despite this great setback, many native-born Japanese Americans later advanced economically by pursuing education into white-collar professions.

    A second wave of immigration occurred after World War II with Japanese wives of US servicemen moving to the United States.

    (For more information on historical experiences influencing Japanese American elders, see Appendix A: Japanese Americans: Significant Dates and Periods in Immigration and History.)

    B. Health Beliefs and Practices

    1. Filial Piety. The Japanese concept of filial piety stems from Confucianism with its origins in China. This Confucian thought was brought to Japan in the seventh century and has been passed down through the ages. In Confucian thought which places importance on family and social order, filial piety was felt to extremely important. Children were expected to obey and respect their parents, bring honor to their parents by succeeding in work, and support and care for parents in their old age. Additionally, for many Japanese immigrants, ‘kodomo no tame ni’ or ‘for the sake of the children’ became the motto by which they endured to bring a better life standard for their children’s generation. Thus an element of expectation from parents and sense of obligation on the part of the children to support and care for their parents may exist. Even though adequate care may be difficult to render by the children, reluctance is often accompanied by guilt if parents are placed in an institutional long-term care facility.

    2. Informed Consent and End of Life Care. It is a common saying that Japanese are born Shinto but die Buddhist. In Shintoism, the emphasis is on purity and cleanliness. Terminal illnesses, dying and death are considered ‘negative’ or impure and akin to ‘contamination.’ Thus, open frank discussions that occur with informed consent procedures, choices in treatment, and advance directives may be difficult at first. However, at some point most Japanese are said to embrace Buddhism in later life. As such, death is considered a natural process, a part of life. Life continues after death in the form of rebirth. They may be more open to end-of-life discussions. Conversion to Christianity or other religions would certainly have some impact on views of death, dying, and end-of-life issues

    Traditionally, organ donation is not favored because of the importance of dying intact, and because the concept of brain death, as opposed to death occurring ‘naturally’ when the heart ceases to beat, is sometimes difficult to understand.

    3. Mental Illnesses. There is a general stigma associated with mental illnesses. Thus there is less seeking of direct medical assistance by either the person afflicted or their family. There is the concept of shame or ‘hazukashii’, in which the individual is taught to avoid bringing shame to his family name.

    IV. Culturally Appropriate Geriatric Care: Assessment

    A. Level of Acculturation

    The initial concerns regarding assessment of the Japanese-Americans include the degree to which a particular person and his or her family still maintain the traditional beliefs of the ethnic group, i.e., their level of acculturation. The degree to which a particular person and his or her family maintain the traditional beliefs is very important because of the marked variability in the Japanese-American community. Depending on the number of generations removed from the original immigrants and the degree to which the traditional values have been held in the family, the person and his family may be more ‘Americanized’, having adopted the Western culture and outlook on life. As in many immigrant families, many individuals of the third generation do not speak the native language of their grandparents, and are culturally quite Westernized. However, traditional values may still influence their decisions. Adopting and embracing the American value of individualism would be a change from the Japanese value of the group (family/society) over the individual.

    B. General Approach

    Courtesy and thoughtfulness are particularly valued in the Japanese culture and these would be appreciated during an assessment.

    An empathetic, blameless, problem solving approach, especially in counseling situations, would work better than a direct and blunt approach, as the Japanese, in general, are indirect.

    (For a complete list of domains of assessment, see Module Four of the Core Curriculum in Ethnogeriatrics.)

    V. Culturally Appropriate Geriatric Care: Treatment

    A. Health Promotion

    In most cases health promotion would not be a difficult topic to discuss with Japanese American elders, especially, immunizations and maintaining healthy habits of diet and exercise. There may be variable receptiveness to the concept of cancer screening, however, which some may feel as the equivalent of ‘looking for something potentially bad.’

    For those Japanese Americans with hypertension or at risk for hypertension, it may be worth noting that educational counseling on a low salt diet may need to be elaborated upon as the traditional diet is high in salt. Some of the high salt dietary items may not be understood as being very salty, such as soy sauce (shoyu), preserved meat and fish, and pickled vegetables. In discussing dietary issues, such as calcium intake for prevention of osteoporosis, it should be noted that the prevalence of lactose intolerance is high.

    B. Working with Families

    In working with families, if the traditional hierarchy is maintained, then the word and decision of the master of the home, the husband, would preside. The next in line for decision-making would be the oldest adult son, though the son would most likely make a decision compatible with what the wife would want. In a very traditional family, one would not see ‘open discussion and arguments’ in front of a physician, as this act would be shameful and reflect negatively on the family name. The physician should be respectful of approaching the appropriate family member.

    C. End of Life Issues

    Dying, death, end-of-life care, advance directive and informed consent should be approached with courteous respect. Open frank discussion on dying and death may be difficult depending on the degree to which a person or his or family maintains traditional culture. Elders may wish to defer decision making totally to their children, often to their oldest son.

    In the presence of a terminal illness, discussions may be a little easier since often the ‘shikata ga nai’ view may be held. The meaning of ‘Shikata ga nai’ is ‘it cannot be helped.’ This view takes any blame or feeling of failure off of the person and his or her family. It embodies an almost stoic acceptance of a difficult circumstance.

    The concept of organ donation may not be received well.

    VI. Access and Utilization

    If there is access to health care services, then they are most likely to be utilized for medical problems, but there would be more reluctance with respect to mental illnesses. The general stigma associated with mental illnesses may reduce the patient and family’s initiative to seek psychiatric assistance.

    Traditional remedies referred to as Kampo may be sought in parallel with ongoing medical treatment. Kampo strives to restore energy flow, and its beliefs have origins in China. Herbs are used and, additionally, use of acupuncture, moxibustion, and shiatsu are not uncommon.

    The Japanese Americans are less likely to utilize nursing homes for their elders compared to their non-Asian American counterparts. As the Confucian influence of filial piety fades with increasing cultural integration and assimilation, it will be of interest to note trends in nursing home statistics. Japanese community organizations in three West Coast cities have built nursing homes especially oriented to Japanese elders, although non-Japanese are also welcome. In Seattle, a study of over 1100 independent older Japanese Americans explored their preference for use of nursing homes. A little over half said they would use a nursing home if they had dementia, but that percentage was reduced by 60% if the Japanese nursing home, Keiro, were not available (McCormick, et al., 1995).

    INSTRUCTIONAL STRATEGIESCASE STUDIES

    Case 1. An 85 year-old Japanese-American woman has resided in her apartment independently since her husband passed away 10 years ago. She has no children. Her landlord has noticed that her previously meticulously manicured garden has become unkempt. In the past year, she has locked herself out of the house four times. The last two months, she has forgotten to pay rent. When reminded, she sent multiple consecutive checks with the wrong dates. Two weeks ago, she left the stove on and burned a pot.
    The concerned landlord had her seen by the geriatric consultative service at a nearby hospital. The social worker at the hospital, arranged for a hired Caucasian caregiver to cook for her. Over the next several weeks, the Japanese-American woman experienced diarrhea, cramping and abdominal pain. She was given over-the-counter Kaopectate and Immodium. Symptoms persisted. She was further evaluated at the medical clinic for her symptoms.

    Questions for Discussion:

    1. What might explain the gastro-intestinal symptoms, the elder was having?
    2. Are there any other services that could be considered for her support?

    Suggestions: One consideration that should be looked into is possible lactose intolerance. Lactose intolerance is prevalent among Japanese. It may be that this woman who also appears to have dementia may have a lifetime of avoiding foods containing lactose. With a non-Japanese caregiver now cooking her meals, it is possible that she is being served foods containing lactose and does not understand or communicate well enough to explain this to the caregiver.
    . A 68 year-old Japanese-American man who was well and independent, and whose only chronic medical condition was eczema, was involved in an automobile accident. At the hospital, he was declared brain dead. His children offered to donate his organs if it could help anyone.

    This Japanese man’s brother and sister flew in from Japan for the funeral and were furious and appalled when they heard that he had become an organ donor. They claimed that he would not have wanted to be an organ donor were he able to express his wishes. They could not understand why he had ‘died’ (brain death) if his heart was still beating. They subtly accused his children of ‘taking his life.’ A terrible rift was created in a previously close-knit family.

    Questions for Discussion:

    1. How could the health care providers have helped to reduce the likelihood of the family rift?
    2. How might health care providers deal with family members who don’t understand ‘brain death’?

    Suggestions: Traditionally, the concept of organ donations for those Japanese-Americans who maintain traditional beliefs, are not well received. This may need to be handled carefully. Usually, when a decision is being made about organ donation, there is limited time to educate extended family members. In as much as possible, however, it may help the family for healthcare providers to be available to extended family members who have difficulty understanding the concept of brain death and organ donation. If it appears that a family rift is looming, having persons of authority and knowledge available for education and counseling to the extended family may ease if not totally prevent the rift. It may be helpful to remember that even in the United States at one time, the concept of brain death and organ transplant was new and met with resistance. With increasing acculturation, the concept of organ donation may become more acceptable.

    STUDENT EVALUATIONQuestions

    1. (True or False) With general longevity among the Japanese, the frequency of silent and undetected dementia may be common. Answer: True

    2. (True or False) The prevalence of lactose intolerance is high among Japanese Americans. Answer: True
    3. . (multiple choice) Regarding mental illnesses,
      a. traditionally, there is a general stigma associated with mental illnesses.
      b. traditionally, there is openness about mental illnesses.
      c. traditionally, mental illness does not bring about the concept of shame or ‘hazukashii.’
      Answer: a
    4. (multiple choice) The Japanese concept of filial piety,
      a. stems from Confucianism with its origins in China.
      b. is a new post World War II philosophy.
      c. is not at all in conflict with institutionalizing one’s parents.
      Answer: a
    5. (True or False) The degree to which the Japanese-American person or family maintains traditional beliefs is of utmost importance. With the passing of generations in the U.S., the person and or his family may have become significantly ‘Americanized’ having adopted the western outlook on life.
      Answer: True
    6. (True or False) In a traditional family, the direct and confrontational style is the best style to use in a family conference. Answer: False

    REFERENCES/ADDITIONAL INFORMATIONBOOKS

    Bisignani, J. D. (1993). Japan handbook (2nd ed.). Chico, CA: Moon

    Goldstein, B. Z., & Kyoko, T. (1975.) Japan and America: A comparative study in language and culture. Rutland, VT, and Tokyo: Charles E. Tuttle.

    Kinoshita, J., & Palevsky, N. (1992). Gateway to Japan (Rev. ed.). Tokyo: Kodansha International.

    Lebra, T. S. (1976). Japanese patterns of behavior. Honolulu: An East-west Center Book, The University Press of Hawaii.

    McBride, M., Morioka-Douglas, N., & Yeo, G (Eds.). (1996). Aging and health: Asian and Pacific Islander American elders (2nd ed.). SGEC Working Paper #3. Stanford, CA: Stanford Geriatric Education Center.

    McDermott, J. F., Jr., Tseng, W.-S., & Maretzki, T. W. (1980). People and cultures of Hawaii A psychocultural profile. Honolulu: John A. Burns School of Medicine, University of Hawaii Press.

    Palafox, N., & Warren, A. (1980). Cross-cultural caring: A handbook for health care professionals in Hawaii. Honolulu: Transcultural Health Care Forum, John A. Burns School of Medicine, University of Hawaii.

    Yeo, G., Hikoyeda, N., McBride, M., Chin, S-Y., Edmonds, M. & Hendrix, L. (1998). Cohort Analysis As a Tool in Ethnogeriatrics: Historical Profiles of Elders from Eight Ethnic Populations in the United States. SGEC Working Paper #12. Stanford CA: Stanford Geriatric Education Center.

    Yeo (Ed.). (2000, October). Core curriculum in ethnogeriatrics (2nd ed.). Stanford, CA: Stanford Geriatric Education Center. [Developed by the members of the Collaborative on Ethnogeriatric Education; supported by Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services.]

    ARTICLES

    Braun, K. L., & Browne, C. V. (1998, November). Perceptions of dementia, caregiving, and help seeking among Asian and Pacific Islander Americans. Health and Social Work, 23(4), 262-273.

    Braun, K. L., & Nichols, R. (1977). Death and dying in four Asian American cultures: A descriptive study. Death Studies, 21, 327-359.

    Campbell, R. & Brody, E. (1985). Women’s changing roles and help to the elderly: Attitudes of women in the United States and Japan. The Gerontologist, 25 (6), 584-592.

    Curb, D., Reed, D. M., Miller, D., & Yano, K. (1990). Health status and life style in elderly Japanese men with a long life expectancy. Journal of Gerontology, 45(5), S206-S211.

    Donahue, R. P., Abbott, R. D., Reed, D. M., & Yano, K. (1986). Alcohol and hemorrhagic stroke: The Honolulu Heart Program. JAMA, 255, 2311-2314.

    Fujimoto, W. Y., Leonetti, J. L., Kinyoun, J. L., Newell-Morris, L., Shuman, W. P., Stolov, W. C., & Wahl, P. W. (1987). Prevalence of diabetes mellitus and impaired glucose tolerance among second-generation Japanese American men. Diabetes, 36, 721-729.

    Iso, H., Folsom, A. R., Wu, K. K., Finch, A., Munger, R. G., Sato, S., et al. (1989). Hemostatic variables in Japanese and Caucasian men: Plasma fibrinogen, factor VIIc, factor VIIIc, and Von Willebrand factor and their relations to cardiovascular disease risk factors. American Journal of Epidemiology, 130, 925-934.

    Koyano, W. (1989). Japanese attitudes toward the elderly: A review of research findings. Journal of Cross Cultural Gerontology, 4, 335-345.

    Launer, L. J., Masaki, K., Petrovitch, H., Foley, D., & Havlik, R. J. (1995). The association between midlife blood pressure levels and late-life cognitive function–The Honolulu-Asia Aging Study. JAMA, 274(23), 1846-1851.

    McCormick, W. C., Uomoto, J., Young, H., Graves, A., Vitaliano, P., Mortimer, J. A., et al. (1995, November). Attitudes toward use of nursing homes and home care in elderly Japanese-Americans. Poster session presented at the 48th annual meeting of the Gerontological Society of America, November 15-19, 1995, Los Angeles.

    McLaughlin, L., & Braun, K. L. (1998, May). Asian and Pacific Islander cultural values: Considerations for health care decision making. Health and Social Work, 232, 116-126.

    Rantanen, T., Guralnik, J., Foley, D., Masaki, K., Leveille, S., Curb, D. J., & White, L. (1999). Midlife hand grip strength as a predictor of old age disability. JAMA, 281(6), 558-560.

    Reed, D. M. (1990). The paradox of high risk of stroke in populations with low risk of coronary heart disease. American Journal of Epidemiology, 131, 579-588.

    Ross, W. G., Abbot, R. D., Petrovitch, H., Masaki, K. H., Murdaugh, C., Trockman, C. et al. (1997, March 12). Frequency and characteristics of silent dementia among elderly Japanese-American men. JAMA, 277(10), 800-805.

    Tomita, S. (1994). The consideration of cultural factors in the research of elder mistreatment with an in-depth Look at the Japanese. Journal of Cross-Cultural Gerontology, 9, 39-52.

    White, L., Petrovitch, H., Ross, W. G., Masaki, K. H., Abbott, R. D., Teng, E. L., et al. (1996). Prevalence of dementia in older Japanese-American men in Hawaii–The Honolulu-Asia Aging Study. JAMA,276(12), 955-960.

    Yano, K., Popper J. S., Kagan, A., Chyou, P. -H., & Grove, J. (1994). Epidemiology of stroke among Japanese men in Hawaii during 24 years of follow-up–The Honolulu Heart Program. Health Reports, 6, 28-38.

    OTHER:

    I would like to thank Dr. Gwen Yeo of the Stanford Geriatric Education Center for her valuable input and chart on Asian/Pacific Islander Elders 65 and over, 1990, selected characteristics.

    INTERNET RESOURCE

    http://www.2hk.mobi

    Appendix A
    JAPANESE AMERICANS (JA)
    SIGNIFICANT DATES AND PERIODS IN IMMIGRATION AND HISTORY

    Japanese immigrants arrive in California; Wakamatsu Colony on Gold Hill.

    Chinese Exclusion Act, stops immigration from China; increased demand for JA immigrants to West Coast; population of married women jumps from 410 in 1900 to 22,193 in 1920.

    San Francisco School Board places children of ‘Mongoloid’
    ancestry in segregated schools.

    24,300

    Primary period of Japanese immigration to the U.S.

    1908

    Gentleman’s Agreement, Japan will not to issue visas to Japanese laborers;
    but wives, children, and families are allowed.

    72,100

    1924

    Immigration Exclusion Act ends all Asian immigration except Filipinos.

    U.S. breaks off relations with Japan after invasion of Nationalist China.

    1941

    Japan attacks U.S. fleet and military base in Pearl Harbor; U.S. declares war on Japan, Germany, Italy; incarceration of JA community leaders.

    1946

    U.S. drops atomic bombs on Hiroshima/Nagasaki, ends war with Japan;
    JA resettlement on West Coast; meet with hostility/housing shortages.

    1952-1956

    Walter-McCarran Immigration and Naturalization Act passed, Asian immigrants
    allowed to become naturalized citizens; repeal of Alien Land Laws in California.

    1959

    Hawaii becomes 50th state; First JA, Daniel Inouye, elected to Congress.

    Commission on Wartime Relocation/Internment of Civilians reviews
    Executive Order 9066 constitutionality, reports ‘personal justice denied’

    Civil Liberties Act, apology/payment of $20,000 to 60,000 survivors.

    First apologies and redress payments sent to survivors, oldest first.

    847,500

    6 Lessons Learned: Businesses

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    Why People Think Services Are A Good Idea

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    What I Can Teach You About Businesses
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